The long-term goal of this project is to understand the utility of home BP monitoring in managing hypertension, role of volume overload in causing hypertension and drug therapy in the treatment of hypertension in hemodialysis patients. We hypothesize that that volume control can improve BP and antihypertensive therapy can regress left ventricular hypertrophy in long-term hemodialysis patients. Specific aims: #1. In a randomized trial of 150 patients we have shown that volume control improves hypertension in hemodialysis patients within 4 weeks that persists at 8 weeks. To improve the diagnosis of hypertension, predict the response to ultrafiltration and explore the mechanisms of hypertension control in hemodialysis patients we propose 4 additional analyses on the data collected. #2. We propose to complete an ongoing randomized controlled trial of beta- blocker versus ACE-inhibitor based antihypertensive therapy in effecting regression of left ventricular hypertrophy. Methods: Aim 1 of the application has 4 analyses which are as follows: 1. To support the use of home BP to diagnose and manage hypertension we will test the relationship of home BP improvement in the ultrafiltration group compared to controls and the agreement with improvement in ambulatory BP. We expect that the agreement between home BP and ambulatory BP will exceed the agreement between dialysis unit BP and ambulatory BP. 2. To uncover the markers of volume overload, we will evaluate a panel of markers that predict BP fall with ultrafiltration. We expect an improvement in ambulatory BP in the ultrafiltration group when patients are volume overloaded as defined by a panel of 4 markers. 3. To evaluate the value of ambulatory BP as a marker of volume overload, we will analyze the relationship of change in patterns of ambulatory BP in the ultrafiltration group compared to controls. We expect that the ultrafiltration group will have fundamental changes in patterns of ambulatory BP as assessed by the trended cosinor model. 4. To determine the contribution of arterial stiffness in causing hypertension, we will analyze the improvement in pulse wave velocity in response to ultrafiltration. We expect that ultrafiltration will lead to improvement in arterial stiffness and ambulatory BP. Aim 2 of the application is a parallel group, active control, single-center, randomized open-label trial comparing the safety and efficacy of lisinopril vs. beta- blocker atenolol-based therapy each administered three times weekly after dialysis on the primary outcome variable of regression of echocardiographic left ventricular hypertrophy. BP control will be achieved by home BP recordings. Significance: Cardiovascular disease is the major cause of death in hemodialysis patients and hypertension a major contributor of cardiovascular disease. The strategies of diagnosis, management and treatment of hypertension in hemodialysis patients developed in this application when applied to a larger population of dialysis patients may result in improved BP control and better cardiovascular outcomes. Novelty: The volume index developed as a marker of excess volume and the trended cosinor model developed to analyze hemodynamic patterns in hemodialysis patients are novel discoveries from our earlier grant. Application of these novel models to randomized controlled trials would transform a mathematical expression to a live clinical tool. PUBLIC HEALTH RELEVANCE: Cardiovascular mortality is the major cause of death in patients on hemodialysis. The long-term goal of this project is to understand the utility of home BP monitoring in managing hypertension, role of volume overload in causing hypertension and drug therapy in the treatment of hypertension in hemodialysis patients. We hypothesize that that volume control can improve BP and antihypertensive therapy can regress left ventricular hypertrophy in long-term hemodialysis patients.